POSTPARTUM HEALTH RELATED QUALITY OF LIFE OF MOTHERS AT 12 WEEKS AFTER VAGINAL AND CAESARIAN DELIVERY IN SELECTED HOSPITALS IN ENUGU NIGERIA

POSTPARTUM HEALTH RELATED QUALITY OF LIFE OF MOTHERS AT 12 WEEKS AFTER VAGINAL AND CAESARIAN DELIVERY IN SELECTED HOSPITALS IN ENUGU NIGERIA
CHAPTER ONE
INTRODUCTION
Background to the Study
Childbirth is an experience full of change, enrichment, and challenge for couples and the family unit (Bloom, 2014). Childbirth takes not just one’s mind and body through a stream of change; it also takes the family through psychological adjustments (Eden, 2014). It is a time when couples as family confront their fears and expectations about becoming parents. In other words, parenthood may have physical and psychological changes in both mother and father depending on the circumstances of pregnancy, labour and mode of delivery.
Vaginal delivery is the birth of off-springs in humans through the vagina (Abedian, 2010). It is the natural method of birth for humans. The different types of vaginal delivery may include Normal/spontaneous vaginal delivery, assisted vaginal delivery, and induced vaginal delivery (Hakeem, 2014). Virtually all types of vaginal delivery produces some changes in a mother’s brain. Since the brain controls or regulates the functioning of the human body, it may be logical to assume a resultant change in functioning of the mother’s body (Glynn, 2014). The actual details in the process of vaginal delivery may determine the degree of impact of childbirth on health and well being (Rice, 2012). This could be evidenced by the fact that the average hospital stay after a normal vaginal delivery is 36-48hours or with an episiotomy [surgical cut to widen the vaginal canal] is 48-60hours (Abedian, 2010).
Caesarean delivery is the birth of off-springs through a surgical procedure in which one or more incisions are made through a mother’s abdomen and uterus to deliver one or more babies (Wiklund, Edman, & Andolf, 2007). It is performed when a vaginal delivery would put the baby’s or mother’s life or health at risk (Abedian, 2010). Some are also performed upon request without a medical reason to do so (Wiklund, Edman, & Andolf, 2007). Caesarean deliveries have been classified in various ways by different perspectives. It is most common to classify Caesarean deliveries by the urgency of performing them. Conventionally, caesarean sections are classified as being either an elective or emergency delivery (Adewara, Omokanye, Balogun, Salaudeen, Saidu, & Jimoh, 2012).
A planned or elective caesarean delivery is an elective surgery, meaning that it is scheduled in advance rather than performed because of an emergency. This confers the ability to perform the delivery at a time when hospital resources are optimal, such as at daytime rather than what might otherwise turn out to be at night. Critics also argue that because physicians and institutions may benefit by reducing night time and weekend work, an inappropriate incentive exists to suggest elective surgery (Gbenga, 2015). Therefore, elective caesarean sections may be performed on the basis of an obstetrical indication, or maternal request.
Rice (2012) argues that planned caeserean delivery may be putting greater strain on the health and well being of mothers than normal vaginal delivery. He noted that the average hospital stay after caeserean delivery is 60-120 hours. This statement eventually questions an affirmation made by Chong and Kwek (2010) that elective caeserean delivery is relatively safe for both mother and fetus. No matter the mode of delivery however, childbirth has some physical and psychological impact on the mother.
Following vaginal or caesarian delivery, mothers may often endure physical pain, haemorrhoids, constipation, urinary incontinence, prolonged haemorrhage, postpartum depression and difficulty regaining pre-pregnancy shape (Nassauer, 2013). Hence, childbirth could be considered a potent stressor (Hakeem, 2014). Therefore the process of birth may mean extra pressure on the functioning of a mother’s general system or her health and well being, which in turn could affect her quality of life.
Quality of life has been defined as a subjective feeling of comfort, happiness and satisfaction with activities of daily living as expressed in her physical and physiological functioning (Global Development Research Center, 2015).
As individuals within families with a newborn find themselves making social, environmental, occupational, physical and psychological adjustments in order to accommodate the care of a newborn; mothers are also expected to adjust from gravid to post-gravid health states in spite of the mode of delivery (Bjelica & Kapor-Stanulović, 2014). How fast this psycho-physiological adjustment of a mother is achieved may set limits to her ability to care for her newborn, as well as her quality of life at every stage in her postpartum period (James, 2008).
Within the African context, women are custodians of the home. In other words, mothers may engage in routine domestic work aside caring for the newborn. With little social support in families where women keep jobs outside home, mothers would have even more work time with the arrival of a new baby. Excessive work may put some strain on a mother’s ability to recover from the physiological demands of childbirth (Centers for Disease Control and Prevention , 2015). In other words, a mother’s perceived feeling of comfort and satisfaction with ability to cope with activities of daily living may be impacted upon. This individualistic perceived meaning to the multidimensional experience of one’s physical health, adjustment to socio-environmental demands, and coping with activities of daily living is generally dubbed “Health Related Quality of Life” (Global Development Research Center, 2015).
Health-Related Quality of Life (HRQoL) involves those aspects of Quality of Life or functioning, which is influenced or limited by health status; and is based on measurable physical, psychological and social dimensions (Baracaccia, et. al, 2013). This may further suggest that Health-Related Quality of Life (HRQoL) means how one’s health status influences one’s ability to cope effectively with activities of daily living. Therefore Health-Related Quality of Life (HRQoL) reflects perceived wellbeing within the physical, psychological and social domains of life. Hence, the link between maternal health status and type of delivery experienced by mothers may be vital to understanding the nature of this property of “Quality” in the life of a mother (Centers for Disease Control and Prevention, 2011).
Health-Related Quality of Life (HRQoL) is rather dynamic just as health and wellness (Baracaccia et. al, 2013). In other words, perceived comfort, happiness and satisfaction with life could change as one experiences change within oneself and his immediate environment. It may then be logical to assume that, Health-Related Quality of Life (HRQoL) in postpartum women change as they proceed from delivery through postpartum period to recommencement of pre-gravid work routines or chores (International Society for Quality of Life Research, 2015).
The World Health Organization thus recognizes Health-Related Quality of Life (HRQoL) as an important indicator along with traditional measures to capture the burden of health conditions (Yakasai & Abubakar, 2014). It is measured to quantify the degree to which a health condition or intervention impacts an individual’s life in a valid and reproducible way (Global Development Research Center, 2015). The gold standard is for individuals to self report their Health-Related Quality of Life (HRQoL). The measure can then be used to determine changes in Health-Related Quality of Life over time such as in clinical trials and observational studies etc, and compare the Health-Related Quality of Life of patients/clients with different conditions (International Society for Quality of Life Research, 2015). Health-Related Quality of Life (HRQoL) is therefore an imperative maternal and child health tool for estimating the positive and negative consequences of mediconursing interactions on health, wellness and functioning from the patient’s/client’s perspective. Thus, the consequences of vaginal or caesarean delivery on maternal health and wellness overtime could be empirically estimated and compared using the HRQoL measure.
According to Yakasai and Abubakar (2014), caesarean delivery is increasingly being used in place of vaginal delivery worldwide due to maternal requests or physician’s suggestions. Although elective caesarean delivery have been pronounced safe for both mother and fetus (Chong & Kwek, 2010), does caesarean delivery have any merit over vaginal delivery with regard to rapid return to optimal Health-Related Quality of Life (HRQoL)? As Gbenga (2015) noted, this question is yet to be fully answered using evidence based methods.
The postpartum period is the recovery period after childbirth (Declercq & Cunningham, 2008). Within this period, several changes take place within the body of a mother geared towards return from a stress/strain bourne situation to a dynamic health state which she had before pregnancy (Romano, Cacciatore, Giordano, & Rosa, 2010). Typically, the postpartum period begins immediately after birth and extends for about six weeks (Torkan, Parsay, Lamiyian, Kazemnejad, & Montazeri, 2009). However, it is expected that beyound six weeks most of the common health problems of the postpartum period such as pueperal blues, bleeding, bowel and bladder dysfunction would have resolved (Bjelica & Kapor-Stanulović, 2014). In otherwords, at twelve weeks mothers are assumed to have regained their health-related quality of life to a reasonable extent irrespective of the mode of delivery. How correct this assumption is, still remains a subject for further study.
Singh, Kaur, and Singh (2015), and Prick, Bijlenga, Jansen, Boers, Scherjon, and Koopmans (2014) argue that there could be a link between return to optimal Health-Related Quality of Life (HRQoL) and parity status, as well as maternal age. In other words, mother’s age and parity status may have an influence on Health-Related Quality of Life (HRQoL) just as mode of delivery may have an influence on Health-Related Quality of Life (HRQoL).
Against this backdrop, this study examines whether HRQoL differed among newly delivered mothers. This study determines how the HRQoL of mothers differ along eight indicators (Physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional wellbeing, social functioning, pain and general health) in relation to the mode of delivery experienced.
Statement of Problem
The postpartum period carry with it critical life events for mothers leading to physiological, emotional and social changes. Postpartum mothers experience certain physical health conditions that may influence their HRQoL, and health of their children
During vaginal delivery, there is a risk that the skin and tissues around the vagina can stretch and tear while the fetus moves through the birth canal. If stretching and tearing is severe, a woman may need stitches or this could cause injury to pelvic muscles that control her urine and bowel function. Additionally, vaginal childbirth may increase blood loss during delivery. This can be fatal, especially when paired with long labour.
Following vaginal delivery, a woman may also experience lingering pain in the perineum.  This is perhaps the most dreaded part for most mothers. Kalagac (2011) in a study on Persistent post-partum pain after vaginal and caesarean delivery among women of childbearing age in Croatia found that women who have delivered vaginally are likely to have problems with bowel or urinary incontinence and perineal pain. They may also be prone to leak urine when they cough, sneeze or laugh. These may impact on a mother’s satisfaction with her health status in unpredictable ways. Thus the fear of some of the disadvantages of vaginal birth makes some mothers and physicians opt for cesarean delivery.
Having a Caesarean delivery may also increase a woman’s risk for physical complaints following delivery, such as pain and soreness at the site of incision (Abedian, 2010). It also increases the risk of blood loss, fatigue and infection. An empirical study by Majzoobi, Majzoobi, Nazari-Pouya, Biglari, and Poorolajal (2014) which compared the Quality of Life in mothers after vaginal and caesarean delivery in Iran noted that pain persisted longer in mothers who had undergone caesarean delivery compared to vaginal delivery; and mothers who had undergone caesarean delivery feel more fatigue even up to one year. In line with this also, Kalagac (2011) in a study on Persistent post-partum pain after vaginal and caesarean delivery among women of childbearing age in Croatia concluded that up to eighteen percent of women who had caesarean delivery experienced chronic pain compared to ten percent of women who had caesarean delivery. No published empirical information to this regard is based on a Nigerian population so far.
From tale and personal observation, following childbirth some women who were known to be energetic and efficient at work begin to display some weakness, sluggishness and non-productiveness on resumption of work after maternity leave. They arrive late to work frequently. They often take excuses and at times completely absent. This often exposes them to conflict at the place of work. From time to time, they would be physically scruffy, emotionally despondent and may have a tendency to defer economically workable tasks. This leaves one pondering on how comfortable a postpartum mother is with daily living; and whether this condition still gives her the potential to accomplish effectively her daily needs and achieve wellbeing or a healthy quality of life.
Childbirth and childcare place immense psychophysical demand on mothers (Eden, 2014). If a mother does not return to optimal health after childbirth, she will not be fit to care for her newborn as well as carry out her activities of daily living to her satisfaction. She may also become prone to certain psychological complications such as post-partum depression which may result in emotional limitations. Physical complications such as chronic post-partum fatigue may result in role limitations. Socially speaking, family interaction between baby and mother (Bonding) and other members of the family unit may be in jeopardy. Economically, poor return to optimal health and well being post-partum could lead to tarnished individual esteem and waste of human resources among essentially employed mothers. In other words, detrimental states of bodily function measured as poor HRQoL scores could arise from poor return to optimal health. Nonetheless, it has been argued that HRQoL is influenced by not only delivery mode (Gbenga, 2015), but age (Global Development Research Center, 2015), and Parity (Singh, Kaur, & Singh, 2015).
The question that quickly comes to mind is “How does the return to optimal HRQoL differ between mothers who experienced Caesarean delivery from mothers who experienced Vaginal delivery?”. How does maternal age influence the return to optimal HRQoL? How does maternal parity status influence the return to optimal HRQoL? This study hopes to answer these questions.
Purpose of Study
The purpose of this study is to compare the postpartum Health-Related Quality of Life (HRQoL) of mothers at 12weeks after vaginal delivery and caesarean delivery in selected hospitals in Enugu, Nigeria.
Research Questions

1. What are the HRQoL mean subscale scores of mothers who had vaginal delivery at 12 weeks postpartum?
2. What are the HRQoL mean subscale scores of mothers who had caesarean delivery at 12weeks postpartum?
3. What is the difference between the HRQoL mean subscale scores of mothers who had vaginal and caesarean delivery at 12 weeks postpartum?
4. What is the difference between the HRQoL mean subscale scores of mothers who had vaginal and caesarean delivery at 12 weeks postpartum based on age?
5. What is the difference between the HRQoL mean subscale scores of mothers who had vaginal and caesarean delivery at 12 weeks postpartum based on parity?

Research Hypotheses

1. There is no significant difference in HRQoL mean subscale score between mothers who had vaginal and caesarean delivery at 12 weeks postpartum.
2. There is no significant difference in HRQoL general mean score between mothers who had vaginal and caesarean delivery at 12weeks postpartum based on age.
3. There is no significant difference in HRQoL general mean score between mothers who had vaginal and caesarean delivery at 12weeks postpartum based on parity status.

Significance of the Study
Any identified difference in postnatal adjustment to optimal HRQoL between mothers who had vaginal delivery and mothers who had caesarean delivery at 12weeks postpartum based on age and parity will uncover the influence of mode of delivery on HRQoL of mothers. The result of this study will serve as evidence for counseling mothers on the choice of a safer mode of delivery considering maternal age and parity status. It will further inform evidence-based but targeted intervention programmes towards an improved postpartum HRQoL for mothers. This it will do by adding more support to already existing knowledge on the extent to which mode of delivery, maternal age and parity influence the rapidity of maternal adjustment from gravid to post-gravid health states. The identified difference in pace of return to optimal HRQoL based on mode of delivery may serve as basis for informed lobbying within policy making circles for regulations that would better serve the interest of mothers. This it will do by lending more empirical evidence to policy making arguments relating postnatal issues such as duration of maternity leave. Since this study is carried out on an indigenous population, the finding of this study will serve as a source of evidence based knowledge to Midwives and Maternal and Child Health Practitioners by adding to existing empirical literature. The findings of this study could result in enhanced HRQoL among mothers in communities at large if Midwives and Maternal and Child Health Practitioners were to use it in crafting maternal and child health programmes.  It will eventually serve as reference for future empirical studies on related topics. The researcher is of the opinion that a study of this nature might help to provide information for evidence based practice, and further assist women in making informed decision.
Scope of the Study
This study is delimited to a comparison of the postpartum HRQoL of mothers after vaginal delivery and caesarean delivery in Enugu metropolis. It is narrowed to establishing differences in postpartum HRQoL at 12weeks of vaginal delivery and caesarean delivery, based on maternal age and parity status. Differences in HRQoL subscales are restricted to include physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional wellbeing, social functioning, pain and general health; as perceived by the mother.
Operational Definition of Terms
HRQoL of Mothers: refers to a self-report of the respondent’s perceived feeling of comfort, happiness and satisfaction with activities of daily living as expressed in her physical and physiological functioning. For this study, it is a self-report based on scores obtained on the eight subscales of the modified RAND 36-Item Short Form Survey HRQoL instrument (Version 1.0) originally developed by The RAND  Corporation. HRQoL includes physical functioning; role limitations due to physical health; role limitations due to emotional problems; energy/fatigue; emotional wellbeing; social functioning; pain and general health of mothers. Each HRQoL subscale has a maximum score of 100 and minimum score of 0. The general HRQoL score has a maximum score of 100 and minimum score of 0 averaged from HRQoL subscales. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%. HRQoL measures health status within the past 4days.
Physical functioning of mothers: refers to the degree to which a mother is able to carry out activities such as walking, running, moving a table, carrying groceries, climbing stairs and grooming within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Role limitations due to physical health of mothers (role function): refers to the extent to which a mother’s physical functioning constraints her on her daily routines, in terms of time spent on routine activities, task accomplishment and effort required within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Role limitations due to emotional problems of mothers: refers to the level to which a mother is hindered in carrying out her daily routine due to feeling depressed or anxious within the past 4days, in terms of time on task, task accomplishment and satisfaction with quality of accomplished task. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Energy/fatigue of mothers: refers to the quantity of vitality which a mother feels within her in terms of how often she feels full of energy and how frequently she feels worn out within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Emotional wellbeing of mothers: refers to the amount of psychological dynamism which a mother experiences in terms of how often she feels nervous, happy, at peaceful and down hearted within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Social functioning of mothers: refers to the magnitude to which physical functioning or emotional problems interfere with a mother’s activities of interaction with family, friends and groups within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
 Pain of mothers: refers to the amount of bodily discomfort and the extent of interference with work or daily activities as a result of bodily discomfort which a mother has within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
General health: refers to the dynamic point in wellness that a mother feels her entire bodily system is functioning, in terms of perceived state of wellbeing, frequency of feeling ill and expectation of an immediate decline in wellbeing within the past 4days. It has a maximum score of 100 and minimum score of 0. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%.
Postpartum HRQoL of Mothers: refers to a self-report of the respondent’s HRQoL within an operationally defined postnatal period of 12weeks. Postpartum HRQoL score has a maximum score of 100 and minimum score of 0 averaged from HRQoL subscales. It will be interpreted as Poor when less than 50%, Moderate when between 50% and 69%, and Good when above 69%. Postpartum HRQoL measures health status within the past 4days.
Mothers after vaginal delivery: refers to mothers who have undergone childbirth in which her live infant passed through her vagina. It will include only normal vaginal delivery.
Mothers after caesarean delivery: Women who have undergone childbirth in which her live infant was retrieved through a surgical incision on the woman’s abdomen. It will include only planned (elective) caesarean delivery.